Emergency Care Part 3: Surgery in Children with Diabetes

1. Emergency CarePart 3: Surgery in Children with Diabetes Presentation title

2. Emergency care Managing DKA 1 2 Treating and preventing hypoglycaemia 3 Surgery in children with diabetes

3. Surgery • Surgery is more complicated when the patient has diabetes • Need to monitor continuously • Risks for: • Hypoglycaemia • Hyperglycaemia • Ketones • Elective surgery only at a centre with expertise in treating children with diabetes

4. Surgery at Echelons 1-2 • Consider surgery at echelons 1-2 only if • Minor surgery • Emergency major surgery

5. General Principles Correct DKA/ketosis before surgery First on a surgical list (ideally morning) Maintain blood glucose of 5–10 mmol/l during and after surgery Frequent monitoring May need repeated doses of short-acting insulin and maintenance IV fluids   No solid food for 6 hours before general anaesthesia

6. Minor Procedures (1) Rapid recovery anticipated: • Early morning procedure • Delay insulin and food until completion of the procedure • Check blood glucose 0-1 hour pre-operatively • After surgery, check glucose, give full dose of insulin and food

7. Minor Procedures (2) Rapid recovery and/or early feeding may not occur: • Give 50% of usual insulin dose • Monitor glucose 2 hours pre-operatively • If glucose above 10 mmol/l: • Give dose of short-acting insulin (0.05 U/kg) OR • Start insulin infusion at 0.05 U/kg/hour • If glucose <5 mmol/l, start IV dextrose (5 or 10%) infusion

8. Post-operation Check blood glucose hourly Start oral intake or continue IV glucose Give small doses of short-acting insulin for hyperglycaemia or for food intake Give the dinner time or evening dose of insulin as usual Because of post-op DKA possibility, more overnight blood glucose monitoring at home or admit to hospital

9. Major Surgery • For emergency major surgery • Correct DKA/ketosis before surgery • Consider transfer to a centre with expertise in treating children with diabetes • Consider major surgery at echelon 1-2 only if: • Dire emergency • Unable to transfer to a centre with appropriate expertise • Take to operating theatre and start DKA protocol simultaneously

10. For elective surgery First on surgical list (ideally morning) If control is uncertain or poor, admit for stabilisation of glycaemic control If diabetes is well controlled, admit to hospital on the day before surgery Only consider surgery once diabetes is stable

11. Pre-operative • In the evening before surgery • Frequent blood glucose monitoring • Usual evening insulin(s) and snack • Short-acting insulin to correct high blood glucose values every 3-4 hours • Keep nil by mouth from midnight • If the child develops hypoglycaemia, start an IV infusion of dextrose (5-10%)

12. Intra- and Post operation • On the day of surgery • Omit usual morning fast or rapid insulin • Consider decreasing or omiting intermediate or long acting morning insulin • Instead give insulin by • IV insulin infusion at 0.05 U/kg/hour OR • Repeated doses of short-acting insulin every 3-4 hours • Give IV fluids (half normal saline with 5% dextrose). • Check blood glucose and electrolytes regularly • DKA can occur during or after surgery

13. Intra- and Post operation • Monitor glucose • 1-2 hourly before surgery • Every 30 minutes during surgery • Hourly post-operatively • Aim for 5-10 mmol/l • Adjust rate of insulin and dextrose-saline • Feed and start regular doses of insulin once awake • Monitor ketones if glucose is >15 mmol/l

14. Questions

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